<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601519
Report Date: 09/24/2021
Date Signed: 09/24/2021 04:41:14 PM

Document Has Been Signed on 09/24/2021 04:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LAFAYETTE HEIGHTS RESIDENTIAL CARE IIFACILITY NUMBER:
075601519
ADMINISTRATOR:MOGADAM, JOANNEFACILITY TYPE:
740
ADDRESS:2267 SHANNON LANETELEPHONE:
(925) 979-1200
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 0DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Joanne MogadamTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/24/21 at 3:45 PM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and met with Licensee Joanne Mogadam. LPA stated the purpose of the visit.

Because Licensee has 0 residents at present, the LPA toured the facility to ensure that no structural changes have been made to the facility and there were none either inside or outside of the facility.

There were no citations issued during the visit.

Exit interview conducted.

A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1